Why Republicans Can’t Do Health Care

After the 1976 election, the Democratic Party seemed to enjoy a commanding position in American politics, with Jimmy Carter ensconced in the White House, a Senate supermajority and an advantage of nearly 150 seats in the House of Representatives. Yet over the next four years the Democrats achieved little of consequence, Carter passed into history as a failure, and Ronald Reagan ushered in a lasting rightward realignment.

I have compared Donald Trump to Carter before, but with the release of the House Republican “replacement” (I use that term loosely) for Obamacare, it’s worth returning to the analogy. It rests, in part, on the work of the political scientist Stephen Skowronek, who argues that certain presidencies are “disjunctive” — straddling a political order passing into history and another one struggling to be born. And “disjunctive” generally means ineffective, because the parties such presidents are leading are likewise trapped between past and future and unable to unify and act.

Carter is Skowronek’s prime disjunctive example, and a variety of writers, including Corey Robin and Dylan Matthews on the left and Reihan Salam on the right, have recently argued that Trump fits the role as well.

Just as Carter sensed that the New Deal-Great Society coalition was no longer viable and campaigned against certain liberal orthodoxies in ’76, so in 2016 Trump offered a vision of the G.O.P. as a nationalist “workers party” in which certain Reaganite pieties would no longer set the terms of conservative debate.

But just as Carter’s mix of proto-New Democrat centrism and old-school liberalism never translated into a workable congressional agenda, Trump’s bridge to a new conservatism will crumble if his party can’t agree on policies that fit his vision.

The health care debate makes this danger particularly clear. In the long Reagan era, the Republican Party was, in effect, the party of the health care status quo — bending to accept certain expansions of the welfare state (S-CHIP, a prescription drug benefit in Medicare) in order to forestall a larger government takeover of health insurance.

By the late 2000s, however, the decline in employer-provided coverage and the steady rise of health care costs made status-quo politics untenable: Too many workers who made too much to qualify for Medicaid were unable to afford insurance. Meanwhile, over the same period, Republicans were winning more working-class votes, which meant that their own constituents increasingly stood to benefit from a coverage-expanding health care reform.

This created a strong incentive for Republicans to accept one. But there were still stronger incentives to resist, because the party’s limited-government ideology was hostile to increased spending, and many of its strongest interest groups stood to lose out from reform. So resist the G.O.P. did — sometimes by embracing a more libertarian vision of health care, but more often by incoherently and opportunistically attacking whatever the Democrats proposed.

This strategy was ultimately a policy failure, and it left Obamacare an established fact. At which point the G.O.P. was boarded and seized by candidate Trump, who clearly grasped the political logic of reconciling his party to some form of coverage expansion, even though he lacked an interest in actually hammering out the details. His campaign thus pointed ahead to a likely future in which the G.O.P. accepts a health care subsidy for the working class, without addressing all the internal reasons that the party can’t agree on what that subsidy should look like.

Those internal tensions that have given us the botch that is the House G.O.P.’s Obamacare alternative. It’s a piece of legislation caught betwixt and between: It includes enough in the way of tax credits and regulation to be labeled “Obamacare lite” by the party’s would-be ideological enforcers, but it also promises to throw many people off the insurance rolls — many Trump voters included — for the sake of uncertain policy goals. Its outline bears some resemblance to what the smartest conservative health policy thinkers favor, but it doesn’t want to spend the money (whether on risk pools or pre-funded health savings accounts or income-linked subsidies) that would make that approach politically viable. And its desire to spend less while keeping Obamacare’s most popular regulations (the ban on discrimination based on pre-existing conditions, above all) promises to make the risk of an insurance death spiral that much worse.

So it’s a bill that nobody on the right much likes: Not libertarians and not reformocons, not right-wing donors and not mushy moderates, not the Tea Party senators who promised full repeal and not the swing-state senators who well know that their own voters want the coverage expansion to endure. As for Americans who aren’t ideologically committed, forget about it: Passing the bill would be an invitation to a political beheading.

But in fairness to its designers, there was no bill that could have united all of the right’s disparate factions, because on health care policy, as on a range of issues, the Republican Party as an organism does not know what it believes in anymore.

Which brings us back to Trump’s resemblance to Jimmy Carter, who presided over a party suffering a similar crisis of belief. The political-science schema that makes the two men comparable figures is more compelling as history than as prophecy: It tells us how Trump could fail; it doesn’t tell us that he necessarily will. A strong-enough, savvy-enough, effective-enough president, placed in the transitional role that Carter occupied, could become transformative rather than disjunctive, and build a new ideological majority amid the rubble of the old.

And Trump does have a few of the necessary qualities. On policy he is incurious yet also more politically savvy than the party’s congressional leaders, more attuned to where his own voters and the country stands. His “workers party” is a more compelling vision for the right’s future than either status quo bias or “tax cuts plus nothing” zeal. With focus, attention and the judicious use of the bully pulpit, he could potentially bigfoot all the right’s ideological factions. Instead of tepidly embracing legislation that doesn’t come close to fulfilling his campaign promises, he could force his party to accept a bill that makes more political sense — be it the more redistributive plan advanced by conservatives like Avik Roy, or the federalist compromise floated by Republican Senators Bill Cassidy and Susan Collins.

Alas, as anyone on Twitter is regularly reminded, focus, attention and judiciousness are all qualities that this disjunctive president lacks. Which is why, even though nothing is inevitable, the Carter precedent — a majority wasted and then lost — looms as this administration’s most likely destination.